Chronic kidney disease: detection and management

Also known as CKD · Chronic renal impairment · Chronic renal failure

GP-fellowship guide to chronic kidney disease: the eGFR-and-albuminuria definition and CGA staging, CKD-EPI 2021 race-free equations with cystatin C confirmation near thresholds, who to screen, progression and referral thresholds, blood pressure targets with RAAS blockade, the SGLT2 inhibitor evidence (DAPA-CKD, EMPA-KIDNEY), statins, anaemia and CKD-MBD monitoring, sick-day rules (SADMANS), metformin dosing by eGFR, contrast precautions and structured medication review.

high24 referencesUpdated 22 Aug 202610 min readVerification in progress

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Key points

Chronic kidney disease is defined by abnormalities of kidney structure or function present for more than 3 months — in practice an eGFR below 60 ml/min/1.73 m² or a confirmed ACR of 3 mg/mmol or more.
Every patient is staged on two axes at once — GFR category (G1–G5) and albuminuria category (A1–A3) — because low GFR and high ACR multiply each other's risk.
The management that changes outcomes is sequential and cheap to state: RAAS blockade first-line with albuminuria, SGLT2 inhibition added on top (DAPA-CKD HR 0.61; EMPA-KIDNEY HR 0.72), blood pressure to target, statins, and ruthless medication stewardship.^[9]^[10]
Most harm in early CKD comes from prescriptions, not the disease: SADMANS drugs during dehydrating illness, NSAIDs, unadjusted metformin, and contrast given without thought.^[19]

Overview

Chronic kidney disease affects roughly one adult in ten, and most of them do not know they have it — which is why detection sits in general practice. Automated laboratory reporting of eGFR with every creatinine transformed detection: referrals to Australian renal services rose by about 40% after its introduction, predominantly older, diabetic patients with stage G3a disease.^[20]

The GP's job divides into four tasks. Detect: test the right people with eGFR and ACR. Stage: classify by cause, GFR category and albuminuria category, then re-check borderline results before committing a label. Protect: blood pressure, RAAS blockade, SGLT2 inhibitors, statins, and removal of kidney-toxic drugs. Refer: know the exact thresholds at which nephrology takes over.^[1]^[2]

References24Show

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[2]Stevens PE et al. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med, 2013.PMID 23732715
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[18]Nderitu P et al. Non-steroidal anti-inflammatory drugs and chronic kidney disease progression: a systematic review. Fam Pract, 2013.PMID 23302818
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[21]McClellan WM et al. Individuals with a family history of ESRD are a high-risk population for CKD: implications for targeted surveillance and intervention activities. Am J Kidney Dis, 2009.PMID 19231753
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